Barriers and facilitators of adherence to awake prone positioning: a qualitative study using the COM-B model

Awake prone positioning (APP) is a recommended therapy for non-intubated ARDS patients, but adherence can be challenging. Understanding the barriers and facilitators of adherence to APP is essential to increase the adherence of therapy and improve patient outcomes. The objective of this study was to explore the barriers and facilitators of adherence to awake prone ventilation using a qualitative approach and the Capability, Opportunity, Motivation-Behavior (COM-B) model.

Semi-structured, in-depth interviews were conducted with patients involved in awake prone ventilation. Data were analyzed using an adapted inductive thematical approach and mapped onto the COM-B model to identify barriers and facilitators to adherence of APP.

Nineteen patients were interviewed (aged 55-92 years). Fifteen themes were identified and mapped directly on to the six COM-B constructs, with "physical challenges" related to physical capability being the primary barrier. These COM-B sub-items reflected five other barriers, including low self-efficacy(M), treatment environment(O), availability of time(O), misconceptions about the treatment(C), and insufficient knowledge(C). Key facilitators in adhering to APP were ability to identify and overcome obstacles(C), availability and affordability of treatment(O), family influences(O), beliefs and trust in treatment(M), fear about the disease(M), and perceived benefits(M). In addition, three factors played the role of both facilitator and barrier, such as media influences(O), healthcare influences(O), and behavioral habits(M).

The COM-B model was proved to be a useful framework for identifying the barriers and facilitators of adherence to awake prone ventilation. The findings suggest that adherence behavior is a dynamic and balanced process and interventions aimed at improving adherence to APP should address the barriers related to capability, opportunity, and motivation. Healthcare providers should focus on providing proper guidance and training, creating a comfortable environment, and offering social support to improve patients' capability and opportunity. Additionally, promoting patients' positive beliefs and attitudes towards the treatment and addressing misconceptions and fears can further enhance patients' motivation to adhere to the treatment plan.